Analysis Conditions Leading to the Capsizing The capsizing occurred in an area to the west of both Current Passage and Race Passage, where the weaker current would have had a less effect on the vessel's behaviour. Tide rips, dangerous to small craft, are encountered in the vicinity of Kelsey Bay and had a major effect on the vessel. Regardless of the amount of expertise and skills required to manoeuvre a vessel caught in strong tidal rips, it is of the utmost importance for a vessel to have good stability. The uniformly low values of the rolling period tests indicate the limited nature of the vessel's transverse stability, particularly in the light condition. Hence, it tended to roll on its homeward voyage when it approached the waters off Kelsey Bay. Strong tidal rips caused the Fritzi-Ann to sheer to port and the tidal stream would have flowed against the starboard bow. When starboard helm was applied with the vessel moving ahead, pressure on the rudder developed a component lateral force to port and, being applied below the vessel's centre of gravity, caused an upsetting moment to heel the vessel to starboard. When the skipper put the engine to full ahead, the propeller delivered maximum thrust to the starboard-directed rudder. This caused such an increase in the upsetting moment to starboard that it overwhelmed the vessel's poor righting ability, resulting in the sudden capsizing. Vessel Stability Figures supplied by the previous owner's marine consultant, after the wooden deckhouse was replaced with an aluminum one in1990, indicate the aluminum deckhouse as having both a lower total weight and a lower centre of gravity, thus tending to improve the vessel's stability. Rolling period tests done on the vessel when new in1969 and after the inclusion of the new deckhouse show an overall reduction in stability, with GM reduced by 0.17m. This reduction in stability, despite the installation of the new deckhouse, should have increased the GM, indicating that, during the interim 21years since its construction, the vessel had been subjected to other changes that eroded its stability. TC accepted the 1990figures as indicative of the vessel's stability at that time, subject to the owner/operator following the instructions provided. In this occurrence, 500prawn traps were stowed on the after part of the weather deck. The instructions that no additional weights be added high on the vessel and gear for fishing operations be stowed as low in the vessel as possible were not followed. About 30percent of the total traps at the stern were situated higher than the deckhouse top, rather than low in the empty hold. The RTL licence granted to the Fritzi-Ann led to practices that further adversely affected the vessel's transverse stability. The area of the deck and platform extensions available for the stowage of traps increased 20percent by adding the second extension, but the trap capacity increased in volume by 67percent. This resulted in the Fritzi-Ann carrying 500traps at an average height about 40percent greater than the 300carried previously as a single licensed vessel (seeFigure1). Figure1. Stowage of prawn traps Stability Assessment Although only applicable to small fishing vessels catching herring or capelin or large fishing vessels, TC Stability Standard STAB4 is also recognized as the most appropriate yardstick to assess the intact transverse stability characteristics of other small fishing vessels of closed construction. Compliance with the minimum stability criteria of STAB4 ensures that fishing vessels maintain adequate margins of intact transverse stability throughout a range of standard loading conditions related to the vessel's intended service. Rolling period tests carried out by the TSB during the investigation process indicated the following: In the light condition with oil fuel and freshwater tanks full, the average transverse metacentric height of 0.31m is 11.4percent lower than the minimum GM0.35m required by STAB4. In the light condition with 500traps on the after deck, the average GMof 0.233m is 33.4percent lower than the minimum required by STAB4, showing a considerable reduction of the already low initial transverse stability due to the weight and location of the fishing traps. The GM obtained by these tests is less precise than that derived from an inclining experiment. They provide only a relative indication of a vessel's initial transverse stability. The uniformly low values of the above results indicate the limited nature of the vessel's transverse stability and that, on its homeward voyage after off-loading its catch, the Fritzi-Ann was in a vulnerable condition. It had little remaining righting ability to withstand any sudden external heeling influences. Light Operating Conditions Vessels such as the Fritzi-Ann are at their highest risk when initially outbound for the fishing grounds and while returning home at the end of a fishing season. During these trips, the general practice is to travel light, with their holds empty and all their traps stowed high up on the main deck. The instruction to stow gear for fishing as low in the Fritzi-Ann as possible creates a problem for the fishers when going to the grounds with fresh ice in a clean fish hold. The labour-intensive work in handling the heavier traps, both in carefully stowing them in the fish hold before departure from port and lifting them onto the deck to bait and set them in strings upon arrival at the fishing grounds, is reduced to a large degree if all traps can be stowed in an accessible position on deck. The same economic pressures were not prevalent on the return voyage of the Fritzi-Ann after discharging its catch at the end of season, when traps could have been placed in the empty fish hold. Nevertheless, the owner/operator elected to stow all the traps on the after deck platform extensions, causing an adverse effect on the stability of his vessel. Trap Size and its Effect on the Vessel's Stability In 1995, acting out of concerns for conservation of prawn and shrimp stocks, DFO specified the required dimensions of traps based on volumetric and mesh size considerations. Since the maximum allowable weight of a trap was not specified, licence holders decided to maximize the catch size by having the traps made more robust to keep their volumetric shape. Thus, the weight of prawn traps has progressively increased toward 5kg. As trap weights are not a consideration in the management of fisheries, their weights are not recorded. TC was not contacted to determine whether there were safety implications. Systemic Shortcoming in Approach to Fishing Vessel Safety In 1990, the stability of the vessel was verified by a marine consultant. The effects of the modifications on the stability of the vessel were investigated for TC acceptance. The same approach was not taken in1999, when further extending the deck to accommodate additional traps, nor was TC advised of this modification. The onus is on the owner/operator to inform TC of any modifications carried out to the vessel. Nevertheless, it is also incumbent upon the inspector to be vigilant and ask the master or the owner if any alterations have been carried out between inspections. There is no system in place at DFO to actively involve TC in formulating DFO rules, regulations, policies and Integrated Fishery Management Plans (IFMP). As this occurrence demonstrates, the lack of coordination between the owner/operator, TC and DFO regarding the RTL policy precluded an objective assessment of the impact of the deck extension and the intended load of 500heavy traps on the stability of the vessel. The need for greater cooperation and harmonization of regulations, policies and practices between the two agencies was recognized more than a decade ago. DFO maintains that its expertise does not extend into establishing specifications for the construction of traps, nor does it possess technical knowledge of safety affecting small fishing vessels. Nevertheless, DFO has not involved TC as an active joint partner in formulating rules, regulations, policies or IFMP. The Memorandum of Understanding (MOU) between TC and DFO respecting Marine Transportation Safety and Environmental Protection, dated April 1996, recognizes that DFO has a legitimate interest in fishing vessels and is to be consulted by TC on the development of safety standards and regulations for these vessels. The MOU does not call for similar cooperation when DFO is formulating its rules, policies and IFMP to ensure that fishing vessel safety is not compromised. Training Special technical skills and knowledge are required to ensure safe and efficient vessel operations. Formal training courses for fishers, including training in MED together with seagoing experience, can provide an enhanced awareness of safe practices during normal and emergency operations. As of 31July2002, every member of the complement of a Canadian fishing vessel is required to successfully complete MED training in basic safety (MED A1) before completing six months on board vessels. In general, few fishers fully understand the principles of ship stability. In this instance, the improper distribution of weights secured high on the after deck severely eroded the vessel's transverse stability and contributed to its capsizing. Completion of formal competency-based training and evaluation courses incorporating the fundamentals of ship stability and structured toward acquiring a certificate of competency would raise the awareness of small fishing vessel operators of the consequences of improperly distributed weights, including prawn traps, stacked high up on the vessel. The skipper of the Fritzi-Ann had no formal training in this regard and could not fully appreciate the reduction in the vessel's stability. The subject of training and certification of fishers, as well as other issues including small fishing vessel stability, effectiveness of Ship Safety Bulletins, unsafe operational practices, and the risk-taking attitude of operators, has been comprehensively addressed in TSB report No. M02W0147 (CapRougeII). The Board, concerned about the safety of a large number of small fishing vessels that are operating without approved stability data, recommended that: The Department of Transport require all existing inspected small fishing vessels currently without any approved stability data be subjected to a roll period test and a corresponding freeboard verification not later than their next scheduled quadrennial inspection. While attitudes and beliefs toward risk form the basis of an effective safety culture, and recognizing the need to initiate a change in attitude among fishers to mitigate risk, the Board recommended that: The Department of Transport, in collaboration with the fishing community, reduce unsafe practices by means of a code of best practices for small fishing vessels, including loading and stability, and that its adoption be encouraged through effective education and awareness programs. The report also points to new initiatives being taken by TC for the development of new Small Fishing Vessel Safety Regulations, due for implementation in 2006. Fishery Management Plans Vessels with RTL and Safety As part of the RTL policy, DFO maintains a database of registered traps that are identified by numbered trap tags, but the database does not record trap weights. The recording of trap weights could provide useful information in determining the stability of the vessel. The transfer of traps from one vessel to another, as in the case of RTL licence, could then be readily monitored. The sharing of this information with TC would provide TC with an opportunity to review the stability of the vessel to ascertain the impact of the RLT licence before DFO issues it. Under the current regime, trap weights and their effects on vessel stability and crew safety were not taken into consideration during the development of DFO management plans. TC was not consulted for input and review of the effects of the management plans on vessel and crew safety. Until 1995, some vessels fished in excess of 1000prawn traps, some of which were transported to the fishing grounds by other vessels. When single licences were granted, the 300-trap limit per vessel alleviated the need to transport traps on a second vessel. The additional conservation measures, introduced in 2000/2001 to set and haul traps only once per day from 0700 to 1900, motivated owners of vessels such as the Fritzi-Ann's to obtain an RTL licence to strive for economic advantage during the short prawn fishing season. DFO does not consider the extension platform at the stern of a vessel to be part of the licensed overall length,7 because the structure does not form an integral part of the hull. Instead, the platform is looked upon as an appendage to the after deck for stowing extra gear. Length restrictions apply to all fishing vessels participating in this fishery. Any vessel owner can apply to reallocate trap limits and DFO does not consider vessel length in the process.8 Within the fleet of approximately 250licensed prawn-fishing vessels, about 35of which received RTL licences, the remainder used 300traps each. Smaller vessels carrying the traps on deck incur some measure of risk by reducing vessel stability. The risk increases significantly when an RTL licence is granted to the smaller class of vessel, which has limited deck space and is more susceptible to capsizing when carrying 500traps at a greater height on deck. The Fritzi-Ann qualified for an RTL licence to carry 500traps. The licensed vessel fishes with fewer traps (500)than two single licensed ones (300+300). It was to stow extra fishing gear on a deck extension placed beyond the licensed length and normal limits of the hull, for which the vessel was not originally designed. This affects the behaviour and safety of a vessel at sea, but was not considered by the owner or the authorities to be a significant design change requiring safety analysis. Approach to Fishery Management Plans and Safety In all IFMP, the DFO's prime concern is for the conservation and sustainability of fish stocks. Consideration for health and safety is mentioned as a general principle statement in management plans. However, the effects of the plans are not being fully considered despite a directive9 issued to the regions on 15February2001, which states in part that, when developing fisheries management plans and policies, all measures be examined to ensure that their effects do not result in unsafe conditions to fishers. The directive also mentions the need to ensure that regional staff involved in developing and approving fisheries management plans are made aware of the importance of considering safety at sea as an issue in fisheries management decisions. Careful consideration of the elements that affect safety of the fishing vessels operations can be reasonably assured by taking into account all the risks and mitigating options. Small Fishing Vessel Safety Review In November2000, the Canadian Coast Guard (CCG) Maritime Search and Rescue, Newfoundland Region, issued a report titled Fishing Vessel Safety Review (less than 65feet), which not only addressed safety issues concerning the Newfoundland and Labrador fleet, but contained a literature review of recent national and international studies and reports. In examining the literature on fishing vessel safety, common elements that affect safety include such long-standing items as a tendency by fishers to accept and take risks for economic gains, poor seamanship practices, improper loading, lack of standards in safety equipment, education, training, and overall operator competency. Studies in all jurisdictions paid special attention to external influences; one of the most striking was fisheries management being carried out with conflicting objectives, where safety was either subordinated or given no consideration at all. The report also proposed recommendations from a CCG perspective, including: Recommendation No.2B In keeping with the spirit and intent of the MOU between TC and DFO respecting Marine Transportation Safety, a process of consultation should be undertaken to address mandates and roles of each department in enhancing safety for the small vessel fishing fleet. Recommendation No.5B The Integrated Fish Management Plan process should give thorough consideration to the possible effects that changes in management plans may have on safety. This would include discussion and consideration of the safety implications of management plan elements during the Industry Advisory Process and in the development of Conservation Harvesting Plans and would be extended to any reviews of licensing, allocation or access issues. To facilitate this objective, there should be a safety representative (TCand/orCCG) participating in the Industry Advisory Process. The Fritzi-Ann was in a highly vulnerable condition, with little remaining righting ability with which to withstand any sudden external heeling influences, and capsized while attempting to counter tidal rips in the vicinity of Kelsey Bay Harbour. The vessel capsized when its transverse stability was compromised by the combined effects of the sudden dynamic external heeling forces, and the weight and location of some 500fishing traps stowed high up above the main deck level. The operator of the Fritzi-Ann was not trained in ship stability and was not fully cognizant of the stability requirements of his vessel. The operator of the Fritzi-Ann did not follow the instructions endorsed by Transport Canada (TC) regarding location of weights and gear. Having no weight restrictions for prawn traps resulted in the use of more robust, heavier traps and increasing the overall weight of the stacked prawn traps on deck, which adversely affected the vessel's stability.Findings as to Causes and Contributing Factors The Fritzi-Ann was in a highly vulnerable condition, with little remaining righting ability with which to withstand any sudden external heeling influences, and capsized while attempting to counter tidal rips in the vicinity of Kelsey Bay Harbour. The vessel capsized when its transverse stability was compromised by the combined effects of the sudden dynamic external heeling forces, and the weight and location of some 500fishing traps stowed high up above the main deck level. The operator of the Fritzi-Ann was not trained in ship stability and was not fully cognizant of the stability requirements of his vessel. The operator of the Fritzi-Ann did not follow the instructions endorsed by Transport Canada (TC) regarding location of weights and gear. Having no weight restrictions for prawn traps resulted in the use of more robust, heavier traps and increasing the overall weight of the stacked prawn traps on deck, which adversely affected the vessel's stability. The Department of Fisheries and Oceans (DFO) does not use a systematic risk-based approach when formulating Integrated Fishery Management Plans (IFMP) and conservation policies. Lack of coordination between DFO and TC to ensure that DFO rules, regulations, policies, practices and IFMP are in harmony with fishing vessel safety requirements continues to place the safety of small fishing vessels at risk.Findings as to Risk The Department of Fisheries and Oceans (DFO) does not use a systematic risk-based approach when formulating Integrated Fishery Management Plans (IFMP) and conservation policies. Lack of coordination between DFO and TC to ensure that DFO rules, regulations, policies, practices and IFMP are in harmony with fishing vessel safety requirements continues to place the safety of small fishing vessels at risk. Safety Action Taken TSB Marine Safety Advisory Early into the investigation of the capsizing of the Fritzi-Ann, the TSB issued Marine Safety Advisory (MSA) No. 02/03 addressed to the Department of Fisheries and Oceans (DFO) and Transport Canada (TC), which identified the absence of maximum allowable weight of prawn traps by DFO and the inherent risks associated with vessels carrying heavier traps, affecting their stability. The MSA also raised concerns that DFO does not consult with TC, while in the process of formulating Integrated Fishery Management Plans (IFMP), in order for TC to assess if the plans jeopardize vessels' transverse stability or have an impact on other aspects of vessel safety. In response, DFO has stated that its expertise does not extend into establishing specifications for the construction of traps, but agreed that fishers need to be made aware of the possible danger of overloading a vessel in such a manner that would jeopardize the vessel's stability. In response, TC is developing new revised fishing vessel regulations that would require a stability assessment of some kind for all fishing vessels. Discussions with stakeholders are in progress on a proposed new requirement that the stability of fishing vessels be assessed in the port departure condition, with cages or traps on deck if so equipped, in addition to the operating conditions already established. Department of Fisheries and Oceans DFO distributed the following document to all vessel owners eligible for a 2003/2004 prawn and shrimp trap licence: Subject: Marine Transportation Safety Board, Vessel Safety The Marine Transportation Safety Board has completed investigation of an incident following the 2002commercial prawn trap fishing season, in which a vessel returning from the fishery with traps on deck, rolled over. Fortunately, there was no loss of life. The Board has expressed concern that the increased average weight of traps in recent years may have been a contributing factor, as well as the number of traps which the vessel was carrying. The Department strongly recommends that vessels, masters and crew engaged in the prawn and shrimp trap fisheries exercise caution in the loading and transport of gear prior to, during and following the fishing season. The Department reminds fishers that alternate vessels or skiffs may be used to transport gear to and from the fishing grounds and during the fishery, provided that the traps are set and hauled from the licensed vessel to which the traps are registered for fishing use. If carried by another Wlicensed vessel, the traps should be carried in an non-fishable condition with no tags attached or snaps on the bridle, as outlined in the commercial harvest plan for replacement traps on board. Also be advised that the Department will provide time for reasonable deployment of vessels to the fishing grounds. If necessary, the season opening may be delayed to provide for such time. The opening date will be announced by a variation order and notice to industry, in lateApril. This document, except for the final paragraph referring to a possible delay of season opening, was also distributed by the Pacific Prawn Fishermen's Association, in its mail out to all Wlicence holders in preparation for the upcoming fishing season. Information has also been included in the IFMP and in the Commercial Harvest Plan. These documents are provided to each licence holder at the time of licence renewal. DFO can take and has taken steps to improve coordination with TC and other agencies involved with vessel and crew safety, such as the Workers' Compensation Board (WCB) of British Columbia. Actions include: A Marine Action Group has been formed in the Pacific Region to promote safety awareness, provide safety education, and foster safe operating practices in the fishing community. The Group includes TC Marine Safety, TSB, the WCB of British Columbia, Fisheries Management, Canadian Coast Guard (CCG) and industry representatives, such as the B.C. Seafood Alliance. Continue work with TC and the WCB of British Columbia to make small fishing vessel owners, masters, and crew aware of safety issues. This will include information in all IFMP about vessel safety, which should improve over time and be made specific to the particular fishery through the advice of TC and the WCB of British Columbia, along with a role for TC and the WCB of British Columbia during advisory committee meetings. Specific to the prawn by trap fishery, DFO will continue to include the advice on vessel safety in the IFMP and provide TC and the WCB of British Columbia opportunities to address vessel and crew safety at the Prawn Sectoral Committee. Further, DFO will consult with TC to address their respective mandates and roles in enhancing safety for the small vessel fishing fleet. This would include improved coordination with TC on the development of IFMP and policies that may affect fishing vessel safety, and the sharing of information pertinent to vessel safety available to DFO.